This document summarizes the key health benefits included in an insurance plan, including deductibles, out-of-pocket maximums, coverage for preventative care, hospital services, prescription drugs, doctors' services, emergency services, mental health services, and other benefits. Preventative care is covered at 100% in or out of network. Coverage levels for services vary depending on whether the provider is in-network or out-of-network. Deductibles and out-of-pocket maximums apply to most in-network and out-of-network benefits.

1. Summary of Health Benefits

2. Deductible Out of Pocket Preventative Care Hospital Services Prescription Services Emergency Services Mental Health Services Other Services Doctor’s Services Click

3. In Network cost $### Plan Year Deductible Out of Network cost $### What is a Network? Health Insurance companies maintain networks consisting of specific hospitals, doctors and other medical providers they have made prior arrangements and relationships with. You should always try to use a provider in network to ensure coverage and a lower deductible. The amount you must pay in a year before you become eligible for insurance benefits .

4. In Network cost $#### Plan Year Out-of-Pocket Out of Network cost $#### The maximum amount you are obligated to pay out-of-pocket each year.

5. Preventative Care 100% of deductible is waived for In-Network and Out-of –Network preventative care for

6. Doctor’s Services Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount. Office Visits Chiropractic $500 max per year Allergy In Network ##% covered after deductible ##% covered after deductible ##% covered after deductible Out of Network ##% R&C after deductible ##% R&C after deductible ##% R&C after deductible

7. Emergency Services Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount . Emergency Room and ER Physician In Network ##% after deductible Out of Network ##% R&C costs after deductible

8. Hospital Services Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount. In-Patient Surgical Facility Supplies Room and Board In-Patient Newborn Care Misc. Hospital Charges Out-Patient In Network ##% after deductible ##% after deductible ##% after deductible Out of Network ##% R&C costs after deductible ##% R&C costs after deductible ##% R&C costs after deductible

9. Mental Disorders Substance Abuse Health Plans will look at what is Reasonable and Customary for doctors in your area and base your reimbursement on that amount. In-Patient Treatment Out-Patient Treatment In Network ##% after deductible ##% after deductible Out of Network ##% R&C costs after deductible ##% R&C costs after deductible

10. Prescription Drug Benefit Retail, up to ## day supply ##% to $#### combined out of pocket maximum Mailorder, up to ## day supply ##% to $#### combined out of pocket maximum

11. Other Services Private Nursing Duty ##% after deductible ##% R&C after deductible Home Health Care 80 Visits ##% after deductible ##% R&C after deductible Disagnostic X-ray, Lab (Outpatient and Inpatient) ##% after deductible ##% R&C after deductible Physical Therapy Occupational and speech ($500 max) (Therapy reviewed for medical necessity after 20 visits) ##% after deductible ##% R&C after deductible Ambulance ##% after deductible ##% R&C after deductible Durable Medical Equipment $### max per calendar year ##% after deductible ##% R&C after deductible